333 Erciyes Med J 2020; 42(3): 333–5 • DOI: 10.14744/etd.2020.45144 BRIEF REPORT – OPEN ACCESS

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Importation and Transmission Routes of COVID-19 into Northern : Considerations and Challenges

Buket Baddal

ABSTRACT Coronavirus disease (COVID-19) that arises from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged from Wuhan, China, and has spread worldwide currently affecting more than 210 countries and territories. This study aims to report the first observed cases in , their importation and transmission routes, and the current challenges of the COVID-19 outbreak. The index case of COVID-19 in Northern Cyprus was identified as a 65-year-old German tourist on 9th March 2020, whereas the first local case was an individual who returned from a trip to England after which multiple transmissions of different origins occurred. Rapid containment measures were enacted to stop the spread of the disease. As of 25th April 2020, 108 COVID-19 cases and four deaths have been observed in the country. Although the epidemiological curve is currently far from a peak, increased preparedness by forming epidemiological surveillance teams to investigate current and future outbreaks, and setting up reference laboratories and centers fully-equipped with next-gen- eration sequencing platforms in which molecular tests can be performed more rapidly and at a larger scale is imperative. Keywords: Index case, COVID-19, Northern Cyprus, local transmission, preparedness, measures

INTRODUCTION Coronavirus disease (COVID-19) has originated from the Wuhan Wholefood market in Wuhan, China and was declared as a pandemic by the World Health Organization (WHO) on March 11th, 2020 (1). Despite the con- Cite this article as: Baddal B. Importation and tainment efforts, public health authorities in China initiated, severe acute respiratory syndrome coronavirus 2 Transmission Routes of (SARS-CoV-2) has rapidly spread, and has been carried to many countries by travelers. There are 2 626 321 COVID-19 into Northern confirmed cases and 181 938 deaths reported globally as of 24th April 2020 (2). Northern Cyprus is located in the Cyprus: Considerations and Challenges. Erciyes Med J Mediterranean region with a population of ~374 000, where tourism as a leading sector and source of income. 2020; 42(3): 333–5. The first COVID-19 case in Northern Cyprus was reported on 9th March 2020 and was a tourist who air-travelled and presented with high fever and other COVID-19 related symptoms after arrival. This study aimed to report first observed cases in Northern Cyprus, their importation and transmission routes, the containment measures, as well Department of Medical as challenges of the COVID-19 outbreak. Microbiology and Clinical Microbiology, Near East University Faculty of MATERIALS AND METHODS Medicine, , Cyprus Case Definition, Case Finding and Data Compilation Submitted 25.04.2020 The definitions of probable and confirmed cases have been based on WHO guidelines (3) and the cases were confirmed at the Burhan Nalbantoglu State Hospital molecular reference laboratory from nasopharyngeal swabs Accepted 26.04.2020 by quantitative real-time polymerase chain reaction (PCR) test as recommended by Centers for Disease Control and Prevention (CDC) (4). Cases were identified when patients were admitted to the state hospital (consequently Available Online Date converted to a pandemic hospital) or contacted the COVID-19 helpline with suspected symptoms. Contact-trac- 04.05.2020 ing of COVID-19 positive cases has been performed by the Primary Health Services Department. Regional and Correspondence demographic data have been obtained from the Northern Cyprus Presidential Crisis Center. Buket Baddal, Near East University Faculty of Medicine, Department of Medical Microbiology and RESULTS AND DISCUSSION Clinical Microbiology, Nicosia, Cyprus Detection of first Imported Cases Phone: +90 392 680 20 00-3056 The first (index) case of COVID-19 in Northern Cyprus was laboratory-confirmed on 9th March 2020 and was e-mail: th th [email protected] announced on 10 March 2020 as a 65-year-old German tourist who arrived in Northern Cyprus on 8 March ©Copyright 2020 by Erciyes 2020 (5). All the individuals within the tourist group were immediately isolated and quarantined. Consequent University Faculty of Medicine - cases linked with the spouse of the German tourist, other tourists travelling within the group, and the bus driver Available online at th www.erciyesmedj.com transporting them were observed, hospitalized and treated. On 13 March 2020, the first local case was identi- 334 Baddal B. COVID-19 in Northern Cyprus Erciyes Med J 2020; 42(3): 333–5

better surveillance analysis, which may be economically challeng- 150 ing. Currently, only symptomatic patients and their close contacts 125 are tested for the disease. An active screening strategy in individu- 100 als who have been actively working during the pandemic and have

75 not self-isolated, as well as random sampling from multiple differ- ent regions, would be a good indicator of active or asymptomatic 50 cases, which may give predictions on the level of herd immunity Number of cases 25 (10). Unfortunately, due to the lack of coordinated reference lab- 0 oratories with trained laboratory staff and diagnostic molecular bi- ology equipment, the current testing strategy may not be sufficient

09/03 11/03 13/03 15/03 17/03 19/03 21/03 23/03 25/03 27/03 29/03 31/03 02/04 04/04 06/04 08/04 10/04 12/04 14/04 16/04 18/04 20/04 22/04 24/04 for the timely identification of all COVID-19 cases.

Figure 1. Number of COVID-19 cases observed in Northern Cyprus between 09th March 2020 and 25th April 2020 CONCLUSION Although the situation in Northern Cyprus is currently steady with- fied as a Northern Cyprus citizen who returned from England, and out a major number of COVID-19 related deaths, reports from subsequent local transmission occurred via individual’s contacts. All other countries show how easily the dynamics can change, partic- proximity-contacts were traced back and quarantined in govern- ularly once restrictions are removed. An active screening strategy ment allocated sites. is required to provide a more accurate number of cases. The con- siderations in this report have been provided to promote decision- Description of the Current Situation makers and authorities to increase preparedness by forming epi- As of 25th April 2020, a total of 108 cases of COVID-19 has been demiological teams to investigate current and future outbreaks, and observed in Northern Cyprus. Of these, 12 cases are currently un- set up reference laboratories and fully-equipped centers in which der treatment, and 92 cases have recovered. The number of cases molecular tests can be performed more rapidly and at a larger scale. detected between 9th March 2020 and 25th April 2020 is shown in Figure 1. No cases have been detected since 20th April 2020 (6, Acknowledgements: We would like to acknowledge the healthcare staff 7). So far, four COVID-19 related deaths have occurred, of which at the molecular reference laboratory at Burhan Nalbantoglu State Hospital two are German (from the tourist group) and two are Northern for providing test results, the Turkish Republic of Northern Cyprus Presi- Cyprus citizens. All German tourists who completed their quaran- dential Crisis Center and Turkish Republic of Northern Cyprus Ministry of tine period and/or treatment have returned to Germany. When Health for providing prompt surveillance data. the epidemiological distribution of COVID-19 was analyzed, nine Peer-review: Externally peer-reviewed. geographical regions within the country were found to be affected. These regions included the capital city Nicosia, Gonyeli, , Conflict of Interest: There is no conflict of interest in this study. , , , Karpasia, Pergamos, and Lefka. Financial Disclosure: The author declared that this study has received When the number of tests performed (n=8747) are considered (as no financial support. of 25th April 2020), ~2.34% of the population in Northern Cyprus (n=374 000) (8) has been tested. REFERENCES

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